The Intersection of Medicine and Dentistry
David E. Klingman DMD
Dentistry is
an interesting profession to consider in the context of developing
interprofessional teams that promote full patient health. Why is this?
Let’s consider three things that occur in Dentistry that may not routinely occur in Medicine and reflect on the impact to patient health and quality of life:
1. Dentists, dental therapists and dental hygienists are more likely to engage with patients multiple times throughout the year, and for longer sessions than may occur with physicians and nurses [particularly for patients with periodontal disease or those receiving restorative procedures who may be seen as frequently as every 3 to 4 months] and during those sessions may be screening for hypertension [blood pressure], diabetes [glucose or HbA1c] or flu/COVID testing [many licensing boars authorize dentists to perform these test with proper training and refrigeration/storage monitoring.
2. Few other health professions use imaging and radiographs as a core element in disease screening and diagnosis [dental radiology, as we’ll see in a case, may provide a window into manifestations of systemic disease].
3. Oral diseases may represent manifestations of systemic disease, and oral disease may contribute to both the incidence and severity of systemic disease [for example, there is at least moderate evidence for the link between oral inflammatory and immune diseases such as periodontal disease and oral mucosal diseases including lichen planus and as we’ll see in another case the potential relationship between oral ulcers and gastrointestinal disease].
Case 1: Metabolic disorders and dental imaging
Image 1 is a
coronal cone beam computed tomographic (CBCT) reconstructed panoramic image of
a patient that shows a diffuse opacification (which in CBCT terms may be
considered to be a variation of a ‘ground or etched glass’ imaging pattern) in
a patient with craniofacial fibrous dysplasia. Fibrous dysplasia is often
considered in the broad context of fibro-osseous lesions; however, its
relevance in the context of genetic/syndrome-related disease since the genetic
abnormality that contributes to the alteration of bone morphology and imaging
pattern may also involve alterations to bone metabolism and involve other
metabolic and endocrine functions such as those seen in McCune Albright
Disease.
Image 1Dentists, dental hygienists and dental therapists may be among the first to recognize this abnormality for three reasons:
1. We order and interpret radiographs on a routine basis.
2. In cases such as this one, the alteration, expansion and increased density of bone may manifest as clinical abnormalities we can easily identify [when the maxilla and mandible are affected, craniofacial shape and dental occlusion may change; when bones such as the sphenoid (where many of the cranial nerves exit) are involved, neurologic functions or pain disorders may be identified; when the orbit is involved there may be visual disturbances; when the mandibular ramus/coronoid and condylar processes and/or zygomatic arch are involved a patient may have limitations opening and closing their mouth his/her mouth].
3. There are at least two non-oral manifestations that can be identified by dental professionals: so-called café au lait macules (that may be identified in the head and neck exam) and metabolic and endocrine disturbances including dysregulation of calcium stores that may be easily identified through review of routine blood work if requested through a review of health history or laboratory tests, or though identification of endocrine disturbances such as pituitary disorders, thyroid function or in some instances precocious puberty in children who may demonstrate mature sexual characteristics at early ages.
Case 2: Oral manifestations of systemic disease
I routinely
ask the question, when I’m speaking to groups of oral health providers, “Where
does the GI tract start?” Invariably, the audience is intelligent and
recognizes that the answer is, “The mouth.”
With that in
mind, Image 2 shows an aphthous-like ulcer in the floor of the mouth in a
patient known to have Crohn’s Disease (inflammatory bowel disease). Crohn’s
Disease often manifests earlier in life (first two decades) and may be
identified by GI disturbances (such as frequent bowel disorders and diarrhea),
failure to thrive and grow along normal height/weight curves) and in
development of painful oral aphthous-like ulcers that may be larger, multiple
and/or recurrent. Crohn’s Disease is also an autoimmune disorder and is often
treated with immune suppressive medications that may challenge the patient’s
immune systems and manifest as oral soreness, oral ulcers, or more aggressive
variants of oral disease such as periodontal disease.
Image 2As oral health professionals, we are in a position to recognize the oral manifestations of systemic disease; there are three instances where gastrointestinal, immune related or (as mentioned in the first case) systemic disease should be considered:
1. Recurrent oral aphthous-like ulcers [which may represent GI disease, immune suppression which may be identified through routine lab test such as a complete blood count with differential [based on an understanding of dental practice acts, in all states dentists may order laboratory tests or requests results from physicians who may assist in lab interpretation] or as more aggressive variants or periodontal disease.
2. Oral ulcers may represent infectious diseases such as herpesviruses [which, unlike aphthae, often involve the gingiva and are routinely associated with fever, malaise, poor appetite etc.], enterovirus infections [that often manifest as oropharyngeal ulcers that may identified during an oral airway/tonsil exam or s hand-foot-mouth disease that oral health professionals may be identified bas asking to examine the patient hands and… yes (if the patient consents) feet] or bacterial infections such as syphilis.
3. Immune senescence [which may occur with increasing age] or immune suppression [which may occur in patients with autoimmune diseases or through chemotherapy in cancer care or bone marrow transplant]; oral ulcers are more common
Putting this
together, oral health professionals should routinely be thinking of themselves
as physicians of the oral cavity and maxillofacial complex/dermatologists of
the head and neck/gastroenterology experts of the GI tract entryway and engaging
other health providers through consultation, requests for health data (such as
lab tests, cardiac status/stress test results, diabetes status/HbA1c testing or
chairside glucose monitoring), routine blood pressure screening, and thorough
head and neck cancer screening and at least selected dermatologic screening of
the visible face, neck, and upper and lower extremities [these are all
examinations and tests that can occur concurrently with initial and periodic
exams and with a well-developed rhythm between the dentist/dental therapist,
dental hygienist, and dental assistant may add just a few minutes to the
routine exam.
Dr. David Klingman is a retired dentist/oral and maxillofacial pathologist with post-graduate training in both hospital-based and outpatient dental residencies and additional training in oral and maxillofacial pathology. He has served and retired as a Colonel in the United States Air Force as the senior consultant in his specialty. He currently resides in Washington State and continues to support dental education speaking and mentoring at the local, state and national level.
